In 1999, the Institute of Medicine released its report, To Err is Human, which estimated that medical errors cause 44,000 to 98,000 deaths annually in the U.S. Healthcare associated infections (HAIs) play a major part in the complications associated with healthcare delivery, with over 2 million infections occurring annually. Much research in control of nosocomial infections and promotion of patient safety has focused on device-related infections. However, recent concerns about respiratory virus epidemics have focused attention on the problem of nosocomial spread of respiratory viruses. Preventing transmission of viral respiratory infections in the intensive care unit (ICU) is essential to promoting patient and provider safety during routine care of patients with such infections and during epidemics. Personal protective equipment (PPE) use decreases nosocomial transmission of epidemiologically important organisms and both organizational and individual healthcare worker (HCW) factors are thought to influence worker self-protective behaviors. However, research examining behavioral strategies to limit HAIs has found strikingly low HCW adherence, and little research has evaluated how both organizational factors and individual HCW factors influence adherence with respiratory precautions to prevent nosocomial respiratory virus infections. Further, patient and family attitudes and behaviors may also play an important role in HCW adherence, but the influence of patient knowledge and attitudes on HCW adherence with PPE has not been investigated. Elizabeth Lee Daugherty, MD, MPH, Instructor of Medicine, in the Pulmonary and Critical Care Division of Johns Hopkins University, has developed this proposal as a collaborative effort among key experts to fill this critical knowledge gap. This proposal will also serve as a key stepping stone toward Dr. Daugherty's goal of becoming an independent clinical investigator and nationally recognized leader in infection control and patient safety, focused on individual and organizational barriers that mediate PPE adherence, HAI rates, and clinical outcomes. As she seeks to achieve her goal, Dr. Daugherty will draw on key intellectual resources by working with Dr. Cynthia Rand, a renowned behavioral psychologist, Dr. Trish Perl, an expert in hospital infection control, and Dr. Peter Pronovost, a recognized authority in patient safety, among others. Dr. Daugherty will engage in a multi-faceted career development program while completing the research outlined in this proposal, under the guidance of her primary mentor, Dr. Rand, Professor of Medicine, Psychiatry, and Public Health at Johns Hopkins. This program will include three main components: 1) one-on- one research mentoring, 2) didactic training in clinical investigation, and 3) career development mentoring, in addition to the successful implementation and conduct of the proposed clinical research plan. All of the members of Dr. Daugherty's mentoring team are fully committed to providing the resources and support that she needs to build on an already productive early career and continue her transition into the fully independent clinical investigator that she hopes to become. The proposal outlined here will provide an essential venue through which to make this expectation a reality. The overall aims of this proposal are to assess the relationship between ICU organizational factors, individual HCW factors, and PPE adherence. We will also develop a novel pilot intervention to improve PPE adherence, which incorporates strategies both to decrease organizational and individual HCW adherence barriers and to empower patients and families to encourage PPE use. Our long term goal is to develop effective, reproducible strategies to lower ICU HAI rates, improve patient safety, and inform HCW and hospital preparedness for response to novel respiratory pathogens, such as SARS or 2009 H1N1 influenza. In specific aim 1, we will assess the association between ICU organizational factors and individual HCW factors on self-reported PPE adherence and directly observed PPE use across a range of ICUs. In specific aim 2, we will evaluate patient and provider barriers to and facilitators of PPE adherence for the prevention of healthcare-associated respiratory virus infections using qualitative methods, and in specific aim 3, we will develop and evaluate the impact of a novel pilot PPE adherence intervention. HAIs are a critical patient safety issue and are associated with significant morbidity and mortality. Little research has examined the influence of individual and organizational barriers to PPE use for control of nosocomial respiratory virus infections. Understanding the factors that influence HCW use of PPE is essential to promoting patient and worker safety during routine care of patients with respiratory infections and also as a model for developing protocols to protect patients and workers during respiratory virus epidemics.